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{{org_field_name}}

Registration Number: {{org_field_registration_no}}

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MRSA Prevention and Management Policy

1. Purpose

The purpose of this policy is to outline how {{org_field_name}} prevents, identifies, and manages Methicillin-Resistant Staphylococcus Aureus (MRSA) infections among the people we support and staff, to ensure safe and effective care delivery. This policy supports compliance with Regulation 12 – Safe Care and Treatment, ensuring that infection prevention measures are in place to protect individuals from avoidable harm and the spread of healthcare-associated infections​.

This policy should be read alongside our Infection Prevention and Control (IPC) Policy and the Department of Health and Social Care Code of Practice on the prevention and control of infections and related guidance. We implement robust IPC systems to ensure care and treatment is provided in a safe way, including assessing risk, preventing avoidable harm, and controlling the spread of healthcare-associated infections in line with Regulation 12 (Safe care and treatment) and CQC’s fundamental standards.

2. Scope

This policy applies to all employees, bank/agency staff, contractors and visiting professionals working in or for {{org_field_name}}, including care staff, nurses (if applicable), domestic/housekeeping staff, maintenance staff, administrative staff, and the Infection Control Lead. It also applies to people using our service, and to visitors where IPC guidance is required. The policy covers both MRSA colonisation (carriage without signs of infection) and MRSA infection (clinical signs/symptoms requiring treatment), and sets out the precautions required for each.

3. Related Policies

• CH11 – Safe Care and Treatment Policy
• CH13 – Safeguarding Adults from Abuse and Improper Treatment Policy
• CH17 – Infection Prevention and Control Policy
• CH18 – Risk Management and Assessment Policy
• CH24 – Management of Accidents, Incidents, and Near Misses Policy
• CH34 – Confidentiality and Data Protection (GDPR) – Service User Policy

4. Policy Statement and Responsibilities

Understanding MRSA

MRSA is a strain of the Staphylococcus aureus bacteria that has developed resistance to commonly used antibiotics. It can live harmlessly on the skin (colonisation) but can cause serious infections if it enters the body, particularly through wounds, urinary catheters, or invasive devices. People most at risk include those with chronic illnesses, open wounds, or recent hospital admissions.

Roles and Responsibilities

• The Registered Manager is responsible for implementing this policy and ensuring all staff are trained
• The Infection Control Lead ({{org_field_infection_control_lead_name}} – {{org_field_infection_control_lead_role}}) oversees infection surveillance, audits, and clinical guidance
• All care staff are responsible for following infection control procedures and reporting concerns promptly
• Healthcare professionals involved in wound care or clinical procedures must document MRSA risk assessments and ensure appropriate treatment protocols are followed

• Domestic/housekeeping lead is responsible for implementing the cleaning schedule, ensuring appropriate disinfectant use, and recording cleaning audits for rooms/equipment used by a person with MRSA.
• Shift lead/senior on duty is responsible for initiating immediate IPC precautions, escalating concerns to the Registered Manager, and ensuring the person’s care plan and risk assessment are updated on the same day.
• Registered Manager is responsible for ensuring timely escalation to external professionals (GP/District Nurse/Infection Prevention team as required), ensuring reporting/notification duties are met, and ensuring learning is captured via governance systems.

Prevention Measures

To prevent the spread of MRSA, {{org_field_name}} implements the following:

• Hand Hygiene: Staff must perform hand hygiene before and after all care tasks, using soap and water or alcohol-based gel
• Use of PPE: Gloves and aprons are worn when delivering personal care, handling wounds, or cleaning bodily fluids
• Environmental Cleanliness: Staff ensure that frequently touched surfaces and care equipment are cleaned and disinfected using appropriate products
• Screening Awareness: Staff are alert to people recently discharged from hospital who may have been screened for MRSA
• Minimising Invasive Procedures: Avoiding unnecessary catheterisation or wound exposure helps reduce infection risk

• Standard precautions (always): We apply standard precautions for all people, including safe management of blood/body fluids, respiratory hygiene, safe disposal of sharps (where used), and appropriate environmental cleaning.
• Equipment decontamination: Reusable care equipment (e.g., hoists, commodes, BP cuffs, thermometers) is cleaned and disinfected after each use, and immediately if contaminated. Where possible, we allocate dedicated equipment to the individual while MRSA precautions are required.
• Laundry management: Linen and clothing are handled to prevent contamination of the environment, stored securely, and washed at appropriate temperatures in line with our laundry procedure. Bags are not overfilled and are securely closed before removal.
• Waste management: Clinical and offensive waste is segregated and disposed of safely in line with our waste policy and local arrangements.
• Antimicrobial stewardship: We support appropriate antibiotic use by following prescriber instructions, monitoring completion of courses, and escalating concerns about treatment failure or recurrent infections.

All infection prevention practices follow current national guidance (including UKHSA/DHSC resources) and are implemented to meet the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, including Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

Care of People with MRSA

When a person we support is diagnosed or suspected to have MRSA:

• A risk assessment is carried out to identify risks to others and tailor the infection control approach
• A care plan is developed to include infection control measures, hygiene routines, and treatment details

Where clinically appropriate and proportionate to the risk, we will use enhanced contact precautions for MRSA, which may include allocating a single room or cohorting, prioritising dedicated toilet facilities, and ensuring wounds are covered with suitable dressings. Decisions are based on an individual risk assessment (including wound exudate, ability to maintain hygiene, cognitive impairment, and presence of invasive devices) and are reviewed regularly.

• Staff follow contact precautions, such as using PPE, disposing of waste and laundry properly, and using single-use items where appropriate
• Visitors and family members are provided with clear guidance to reduce cross-contamination risk

Visitors will be asked to clean their hands on entry and exit and follow any additional precautions advised by staff (for example, wearing PPE if providing direct personal care). Visiting will not be restricted solely due to MRSA status unless there is an outbreak management reason identified through risk assessment.

• The person’s dignity is maintained at all times, and they are supported to understand and manage their condition

Care staff must never stigmatise or isolate individuals unnecessarily; instead, infection control is embedded respectfully into everyday care practices.

Treatment and Medical Management

Treatment decisions are made by the person’s GP or community nurse. This may involve:

• Topical decolonisation (e.g. nasal ointments, antimicrobial washes)
• Antibiotics for active infections
• Wound care support

All prescribed treatment (including decolonisation regimes) must be recorded in the medication administration record (MAR) and/or clinical treatment records, including start/end dates and review arrangements. Staff must monitor and record response to treatment and escalate promptly to the prescriber (GP/District Nurse) if there are signs of deterioration, spreading infection, systemic symptoms, or failure to improve within expected timeframes.

Care staff assist by monitoring for signs of infection (e.g. redness, heat, swelling, pus), supporting adherence to treatment, and alerting medical professionals to concerns promptly.

Reporting and Notification

If MRSA is diagnosed, {{org_field_name}} will:

• Record the infection in the individual’s care plan and risk log
• Inform the Registered Manager and Infection Control Lead
• Liaise with the person’s GP, district nurse, and other professionals involved

• Outbreak escalation: Where we identify linked cases or have concerns about an outbreak, the Registered Manager will seek advice and escalate to the appropriate local Health Protection/IPC team in line with local arrangements and will implement outbreak control measures (including enhanced cleaning, staffing controls, and communication updates).
• CQC notifications (Regulation 18): The Registered Manager will notify CQC without delay of any incident that meets Regulation 18 notification criteria (for example, death, serious injury, allegations of abuse, or an event that stops the service running safely and properly). MRSA in itself is not automatically notifiable; however, if MRSA is linked to a notifiable event (for example, hospital admission with serious harm, death, or major service disruption/outbreak impacts), we will submit the appropriate notification and record the rationale.

Outbreak Management and Service Continuity

An outbreak may be suspected where there are 2 or more linked infections/colonisations with epidemiological connection (e.g., same unit/shift/time period) or where advised by the local IPC/Health Protection team.

On suspicion of an outbreak, we will:

• open an outbreak log and begin a same-day review of possible links (locations, staffing, equipment, wounds/devices)
• implement enhanced cleaning and disinfection and review PPE compliance immediately
• review staffing deployment to reduce cross-transmission risks
• ensure residents, relatives and staff receive proportionate information and reassurance
• seek external IPC/Health Protection advice and follow any instructions provided
• record actions, decisions and learning through our governance system (Regulation 17).

Staff Safety and Support

Staff who come into contact with MRSA are protected by standard infection control measures. If staff are colonised or infected, occupational health support is provided, and they are risk assessed before returning to frontline duties. Staff are reminded that good hygiene practices protect both themselves and those they care for.

Education and Training

All staff receive infection control training on induction and annually, including:

• Understanding MRSA and how it spreads
• Proper hand hygiene techniques
• Use and disposal of PPE
• Safe handling of waste and laundry
• Responding to suspected infections

Training is delivered by the Infection Control Lead or qualified trainer and is updated in line with national guidance.

Monitoring and Audit

The Registered Manager and Infection Control Lead will:

• Audit infection control practices quarterly

Audits will include (as a minimum) hand hygiene observation, PPE compliance, environmental cleaning checks (including high-touch points), equipment decontamination records, and care plan/risk assessment documentation quality. Audit findings will be actioned with named owners and timescales, and re-audited to confirm improvement.

• Review all MRSA cases to identify learning
• Monitor PPE usage and hygiene compliance
• Ensure documentation of care plans and communication logs

Audit results feed into the governance framework under Regulation 17 – Good Governance and are used to improve safety and learning​.

5. Policy Review

This policy will be reviewed at least annually and immediately following any MRSA outbreak, any significant MRSA-related incident (including hospital admission or death linked to infection), any relevant CQC feedback/inspection outcome, or updated national/local guidance (including UKHSA/DHSC/CQC updates). The Registered Manager will ensure staff are informed of changes and that training/competency updates are completed where required.

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Responsible Person: {{org_field_registered_manager_first_name}} {{org_field_registered_manager_last_name}}
Reviewed on: {{last_update_date}}
Next Review Date: {{next_review_date}}
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